Adverse Outcomes in ED Pre Syncope Patients: A Prospective Cohort Study

Transcription

1 Adverse Outcomes in ED Pre Syncope Patients: A Prospective Cohort Study CAEP Vancouver June 2013

2 Venkatesh Thiruganasambandamoorthy MBBS Aparna Vaidyanathan MBBS Lisa Calder MD Valentina Donici DEC George Wells PhD Ian Stiell MD Department of Emergency Medicine Ottawa Hospital Research Institute University of Ottawa, Ottawa, ON Funded by the PSI Foundation and the Department of Emergency Medicine, University of Ottawa

3 The authors have no conflict of interest to declare

4 Pre Syncope: The Clinical Problem Pre syncope is sudden onset of a feeling of impending LOC Pre syncope is poorly studied Most studies combine syncope and pre syncope Guidelines and experts conclude that syncope evidence not applied to presyncope ED burden, management and outcomes not known

5 Objectives To improve our understanding of ED pre syncope by determining: 1) Frequency of ED pre syncope visits 2) ED management 3) Short term and long term prognosis

6 Methods Design: Prospective cohort study Setting: 2 academic EDs Subjects: Adults ( 16 years) with pre syncope within past 24 hours Exclusion: Syncope, mental status changes, seizure, significant trauma, alcohol/drug abuse Study Period: October 2010 to August 2012 (23 months) Study Protocol: Treating ED physicians screened and recruited patients after consent Data collected: demographics, event and medical details, ED management, disposition and physician prediction probability

7 Methods Outcome Measures 1) Short term (within 30 days of ED visit) outcomes: Death, MI, arrhythmia, structural HD, aortic dissection, PE, severe pulmonary HTN, SAH, significant hemorrhage, any other serious condition 2) Long term (31 days to 1 year) outcomes: Death, arrhythmia, structural HD, or cardiac procedures Outcome Assessment: Electronic health records and telephone follow up; confirmed by two blinded EPs

8 Patient Flow Total ED visits (N=263,218) Visits screened (N=6,264) Syncope = 2,372 Not pre-syncope = 2,163 Confusion = 135 Alcohol/drug related = 45 Head trauma = 30 Language barrier = 15 LWBS = 123 Eligible pre-syncope visits (N=1,270; 0.5%) Double enrolments = 53 Refused = 18 Missed = 318 (25%) Patients included (N=881) 75% recruitment Kappa N= (95% CI : )

9 Patient Characteristics (N=881) Age in years, mean (range) 55.5 (17 103) Female (%) 55.9 Arrived by ambulance (%) 55.3 Witnessed (%) 64.7 Medical History (%) Hypertension 35.3 Coronary artery disease 12.9 Atrial fib/flutter 8.9 Syncope 5.0 Congestive heart failure 2.6

10 Final ED Diagnosis: 881 Pre Syncope Patients Orthohypo 12.3% Cardiac 7.7% Outcome in ED 2.9% Syncope/Seizure 0.5% Cause NYD 38% Vasovagal 39.5%

11 ED Management & Outcomes N=881 (%) Investigations performed 96.9 Referred to specialists in ED 10.4 Admitted 4.7 Total outcomes within 1 year 7.6 Cardiac outcomes within 1 year 5.3 Short term outcomes 4.4 In ED 2.9 After ED disposition 1.5 Long term outcomes 3.2

12 Short Term Serious Outcomes (N=881) Serious Outcomes Total (N=39) In ED (N=26) After ED Disposition (N=13) Death 2 2 Cardiac Syncope New/uncontrolled Afib 5 5 Sinus node dysfunction Complete AV block 4 4 MI Ventricular arrhythmia ICD malfunction 1 1 GI bleed 2 2 PE Others

13 Short Term Outcomes After ED Disposition Number of Serious Outcomes Death OH MI PC Stroke Brain Mets PE Arrhythmia Days After ED Visit

14 Long Term Serious Outcomes (N=714) Serious Outcomes (N=23) Deaths unknown/related 2 Deaths unrelated 8 Cardiac 21 Arrhythmia 16 New Afib 8 SVT 1 Sinus node dysfunction 1 Complete heart block 4 Ventricular tachycardia 2 Structural HD 2 Cardiac interventions Ablation 4

15 ROC Curve Physician Outcome Prediction AUC: 0.62 (0.49, 0.75)

16 Conclusions Largest prospective study to date ED pre syncope is not uncommon Associated with serious outcomes in the short and long term Outcome types are similar to syncope We did not observe any new types of outcomes No literature to help EP to identify those at risk after ED disposition There is a need to identify those at risk for short term and long term outcomes

17 Limitations Limited to two large tertiary hospital EDs Only 7% of patients had IRR assessment for study inclusion No comparison with syncope cohort yet

18 Future Directions Check provincial coroner s database for outcomes among study patients Compare outcomes among syncope and pre syncope patients Once the syncope risk tool is developed will validate it on the pre syncope cohort

19 Acknowledgements The dedication and support of all the physicians and residents at The Ottawa Hospital Study nurses: Pam Ladouceur, Mackenzie Eaton, Sarah Gaudet, Karen Pratt Dr. Muhammad Mukarram, Natacha Leduc, My Linh Tran, Sheryl Domingo Marco Guarino, Cindy Campbell Angela Marcantonio Cathy Clement

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